The challenges of integrating cultural competence into undergraduate medical curricula across Europe : experience from the C 2 ME “ Culturally competent in medical education ” project

Providing high quality care to socially and culturally diverse populations is challenging. Many organizations concerned with quality and equity in health care have called for physician training in cross cultural communication as one strategy for ensuring patient-centered health care for all, but little is known about how to effectively and sustainably integrate such teaching into the medical school curriculum. The C2ME "Culturally Competent in Medical Education" is a European project whose aim was to contribute to the integration of cultural competence teaching in undergraduate medical curricula across Europe. In order to foster exchange among medical schools about cultural competence training, C2ME organized a symposium at the 2014 European Association for Communication in Health Care (EACH) conference. The symposium highlighted the variety of teaching approaches and methods that are used to teach cultural competence as well as the the institutional challenges that make integration of cultural competence into the curricula difficult. There is a need for greater exchange of experiences and best practices among European medical schools to overcome these challenges.


Introduction
Providing high quality care to socially and culturally diverse populations is challenging.Difficulties may arise from Hudelson P, Dogra N, Hendrickx K, Verdonk P, Essink-Bot M, Suurmond J MedEdPublish https://doi.org/10.15694/mep.2016.000010 the diversity of patients' health beliefs, values, preferences behaviors and healthcare needs and from the challenges of communicating effectively across language and cultural differences.Communication barriers complicate the task of identifying and responding effectively to patients' needs and expectations.
Many organizations concerned with quality and equity in health care have called for physician training in cross cultural communication as one strategy for ensuring patient-centered health care for all (General Medical Council and Postgraduate Medical Education and Training Board, 2005;National Quality Forum (NFQ), 2009;The Joint Commission, 2010).Both the EU and the WHO Regional Office for Europe have called for cultural competence training of health professionals as part of a broad strategy to tackle health inequities and ensure quality health care for increasingly diverse populations (Council of Europe, 2011;World Health Organisation, 2010).
This has resulted in a number of organizations developing principles and standards for cultural competence training of physicians (American Institutes for Research, 2002;Gilbert, 2003;Liaison Committee on Medical Education, 2014;Like, Steiner, & Rubel, 1996;Van Herwaarden, Laan, & Leunissen, 2009) However, despite a burgeoning literature on methods for teaching different components of cultural competence (American Institutes for Research, 2002;Beach et al., 2005), less is known about how to effectively and sustainably integrate such teaching into the medical school curriculum.Difficulties include a lack of clarity on what should be taught and when, a lack of institutional leadership and support for cultural competence teaching, a lack of faculty development for cultural competence teaching and a lack of evaluation of the effectiveness of such teaching (Cuff & Vanselow, 2004;Dogra, Reitmanova, & Carter-Pokras, 2009, 2010;Lipson & DeSantis, 2007;Lu, Tsai, & Tseng, 2014;Wachtler & Troein, 2003).
These difficulties are common to medical curriculum change in general, and recommendations of the International Association for Medical Education (AMEE) for integrating professionalism into the curriculum seem equally relevant for cultural competence: agree on learning objectives, structure the curriculum to integrate learning across all years, develop a curriculum framework that takes into consideration different learning models, ensure adequate role modeling, and assess trainee learning (O'Sullivan, van Mook, Fewtrell, & Wass, 2012).Faculty development, in particular, has been touted as an instrument of curricular and institutional change (Steinert, Cruess, Cruess, Boudreau, & Fuks, 2007), and may be an effective strategy for effectively and sustainably integrating cultural competence into the medical curriculum (Mihalic, Dobbie, & Kinkade, 2007) and reaching those medical teachers who still see cultural competence as a "politically correct irrelevance that is simply common sense" (Dogra et al., 2009)(p. 5).While a few examples exist in the literature of training initiatives for medical faculty (Berger, Conroy, Peerson, & Brazil, 2014;Ferguson, Keller, Haley, & Quirk, 2003;Kai, Spencer, & Woodward, 2001) (Perlman, Christner, Ross, & Lypson, 2014), more mapping and exchange of experiences and "best practices" across institutions regarding the integration of cultural competence into medical teaching is needed to move the field forward (Dogra et al., 2009).

The C2ME Project
The C2ME project "Culturally Competent en Medical Education" is a European project funded by the EACEA ERASMUS Life Long Learning Program of the EU, involving medical schools in 11 European countries.The aim of C2ME was to facilitate the integration of cultural competence teaching in the undergraduate medical curriculum and address some of the key challenges mentioned earlier (Suurmond, Hudelson, & Dogra, 2015).
In an effort to foster an exchange of experiences among C2ME and other institutions, a symposiums was organized at the 2014 European Association for Communication in Health Care (EACH) conference.At the symposium, several C2ME partners presented their cultural competence training programs.Differences and similarities in approaches to cultural competence were highlighted, and discussion focused on identifying common challenges and promising practices across institutions.Below, we summarize the main points from the symposium.

Diverse approaches for common goals
Participants were generally in agreement about the knowledge, attitudes and skills needed to work effectively with diverse patient populations.Those mentioned included: Respect and tolerance for difference Awareness of one's own culture (including medical culture), and its impact on communication and care Awareness of the risks of stereotyping and prejudice in healthcare Knowledge of the social, cultural and linguistic factors that affect communication and care Knowledge of the sociodemographic and epidemiological characteristics of locally relevant patient populations The ability to explore/identify social and cultural factors affecting care The ability to exchange information in a way that is relevant and understandable for the patient (including working with an interpreter) However, different vocabularies were used to discuss the challenges and strategies related to caring for diverse populations.While some C2ME project partners talked about "(cross/inter/trans)cultural competence", others talked about "diversity training", and yet other talked about developing "migrant friendly" hospitals and services.Some partners focused on the care of "migrant" populations (often narrowly focused on asylum seekers and undocumented immigrants), while others were more focused on racial/ethnic minorities.Dimensions of diversity (nationality, language, legal status, race/ethnicity, gender, socioeconomic status) were also given different levels of consideration.It was noted that the lack of a common vocabulary both reflect and result in different aims and strategies in medical education and can make it more difficult to recognize common ground when it exists.
The organization of medical studies also differed across C2ME partner institutions and influenced when and how cultural competence appeared in the curriculum.Undergraduate medicine may be taught in four, five or six-year programs, with some institutions using a problem-based approach to learning.Cultural competence topics may be introduced at different moments in the curriculum, sometimes as obligatory courses and sometimes as electives.Some topics may be covered in one-time encounters, while others may involve several teaching encounters over one or more years.These differences reflected context-specific experience, constraints and opportunities.
The time and resources allocated for cultural competence teaching also varies, and leads to to different strategies to ensure cultural competence teaching.For example, some institutions have social scientists and other cultural competence specialists on staff while others rely on general medical staff to teach cultural competence topics.Teaching and assessment methods also vary widely, and include online lectures, videos, reflective exercises, roleplays, community visits, and self-directed learning, and reflective writing.A number of innovative methods have been developed, but forums for exchange of methods and materials among European institutions (such as MedEdPortal.org in the USA) are lacking.